Gutfinger D E, Ott R A, Miller M, Selvan A, Codini M A, Alimadadian H, Tanner T M
Division of Cardiothoracic Surgery, University of California Irvine Medical Center, Orange 92668, USA.
Ann Thorac Surg. 1999 Mar;67(3):610-3. doi: 10.1016/s0003-4975(98)01201-6.
The use of the intraaortic balloon pump (IABP) in patients undergoing coronary artery bypass grafting has been traditionally associated with a high complication rate and adverse outcomes. However, recent reports show that many of these catastrophic outcomes can be avoided by preoperatively placing the IABP in high-risk patients. To further validate these reports, we defined a set of liberal criteria for preoperative IABP insertion and applied them to a series of elderly patients (70 years or older) undergoing isolated coronary artery bypass grafting.
Two hundred six consecutive patients who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass were retrospectively reviewed. A rapid recovery protocol emphasizing reduced cardiopulmonary bypass time, an anesthetic protocol for early extubation, perioperative administration of corticosteroids and thyroid hormone, and aggressive diuresis was applied to all patients. Patients who required an urgent operation because of failed percutaneous transluminal coronary angioplasty, a critical left main stenosis (70% or greater), pronounced left ventricular dysfunction (left ventricular ejection fraction 40% or less), or unstable angina refractory to medical therapy or who required an emergency reoperation received preoperative IABP support.
The 30-day mortality rate for the entire group was 4.4%. There were 97 patients (47%) who received a preoperative IABP (group II) in comparison with 109 patients (53%) who did not fulfill the preoperative insertion criteria (group I). Patients in group II had a lower left ventricular ejection fraction (mean, 46% versus 59%, p<0.001) and a higher incidence of congestive heart failure (35% versus 17%, p<0.01) and acute myocardial infarction (37% versus 17%, p<0.01) than patients in group I. The average postoperative hospital length of stay for patients in group II was slightly longer than for those in group I (9.0+/-10.5 versus 6.0+/-3.7 days, p<0.01). However, there were no statistically significant differences in complication or mortality rates between the two groups. Only 2 patients (2.2%) had complications related to IABP insertion. Lower extremity ischemia occurred in both patients, and both were treated successfully with thromboembolectomy.
Liberal preoperative insertion of the IABP can be performed safely in high-risk elderly patients undergoing coronary artery bypass grafting, with results comparable to those in lower risk patients.
传统上，在接受冠状动脉旁路移植术的患者中使用主动脉内球囊泵（IABP）与高并发症发生率和不良结局相关。然而，最近的报告显示，通过术前将IABP应用于高危患者，可以避免许多此类灾难性结局。为了进一步验证这些报告，我们定义了一套宽松的术前IABP置入标准，并将其应用于一系列接受单纯冠状动脉旁路移植术的老年患者（70岁及以上）。
回顾性分析206例连续接受体外循环下单纯冠状动脉旁路移植术的患者。所有患者均采用强调缩短体外循环时间的快速康复方案、早期拔管的麻醉方案、围手术期应用皮质类固醇和甲状腺激素以及积极利尿。因经皮腔内冠状动脉成形术失败、严重左主干狭窄（70%或更高）、明显左心室功能障碍（左心室射血分数40%或更低）、药物治疗无效的不稳定型心绞痛而需要紧急手术或需要急诊再次手术的患者接受术前IABP支持。
整个组的30天死亡率为4.4%。97例患者（47%）接受了术前IABP（II组），而109例患者（53%）未达到术前置入标准（I组）。II组患者的左心室射血分数较低（平均46%对59%，p<0.001），充血性心力衰竭（35%对17%，p<0.01）和急性心肌梗死（37%对17%，p<0.01）的发生率高于I组患者。II组患者术后平均住院时间略长于I组患者（9.0±10.5天对6.0±3.7天，p<0.01）。然而，两组之间的并发症或死亡率没有统计学上的显著差异。只有2例患者（2.2%）出现与IABP置入相关的并发症。两名患者均发生下肢缺血，均通过血栓切除术成功治疗。
对于接受冠状动脉旁路移植术的高危老年患者，术前宽松置入IABP可以安全进行，结果与低风险患者相当。
